Friday, January 28, 2011

Which oral appliance works best for treating sleep apnea?.

I usually know what type of oral appliance, CPAP, BiPAP or surgery will best suit my patient with obstructive sleep apnea after a short interview and exam. Success is not only efficacy of the appliance but also compliance which is a complex issue poorly addressed by randomized trials. The way the patient responds to the exam, impressions and bite often give the final clues to which treatment will be most beneficial. (many types of appliances are shown on the I HATE CPAP! site)

I present below a recent study on which appliances are the most effective. I review the information but I would like to make some personal comments about evidence based medicine and how it ignores the clinical knowledge and experience of trained physicians and dentists. Having done thousands of appliances I believe I am very adept at determining which patients will do best with various appliances. Unfortunately, clinical experience is not easy to integrate into randomized controlled studies. In fact, clinical experience and "gut feelings" about patients are ruled out of these studies. Randomized controlled studies work best with a limited number of variables. A problem many patients who try oral appliances have is that there dentist was trained by a manufacturers course and the doctor only has a single tool in his belt or only one appliance he understands and is comfortable using.

I teach a dental sleep medicine course that extensively covers the entire field of dental sleep medicine. I do give dentists who take my course a handful of appliances that are extremely effective for different patient groups. I also know that experience is vital to treating patients and therefore offer unlimited phone follow-up for 6 months with doctors that I train. I review sleep studies and frequently help them thru the diagnostic regimen to pick an appropriate appliance.

My article review follows and I include the PUB MED abstract with additional comments.

A brand new article looked at the effectiveness of various oral appliances. They found 1475 articles comparing efficacy of various appliances. The study showed that 116 of these studies compared an oral appliance to a control. They gave weight to only 14 of these studies that were randomized controlled trials (RCTs). All of the studies concerned MAD or mandibular advancement devices. The study concludes that "The evidence shows that there is no one MAD design that most effectively improves polysomnographic indices, but that efficacy depends on a number of factors including severity of OSA, materials and method of fabrication, type of MAD (monobloc/twin block), and the degree of protrusion (sagittal and vertical). These findings highlight the absence of a universal definition of treatment success. Future trials of MAD designs need to be assessed according to agreed success criteria in order to guide clinical practice as to which design of OAs may be the most effective in the treatment of OSA."

Discipline of Dental Public Health.AbstractOral appliances (OAs) are increasingly advocated as a treatment option for obstructive sleep apnoea (OSA). However, it is unclear how their different design features influence treatment efficacy. The aim of this research was to systematically review the evidence on the efficacy of different OAs on polysomnographic indices of OSA. A MeSH and text word search were developed for Medline, Embase, Cinahl, and the Cochrane library. The initial search identified 1475 references, of which 116 related to studies comparing OAs with control appliances. Among those, 14 were randomized controlled trials (RCTs), which formed the basis of this review. The type of OA investigated in these trials was mandibular advancement devices (MADs), which were compared with either inactive appliances (six studies) or other types of MADs with different design features. Compared with inactive appliances, all MADs improved polysomnographic indices, suggesting that mandibular advancement is a crucial design feature of OA therapy for OSA. The evidence shows that there is no one MAD design that most effectively improves polysomnographic indices, but that efficacy depends on a number of factors including severity of OSA, materials and method of fabrication, type of MAD (monobloc/twin block), and the degree of protrusion (sagittal and vertical). These findings highlight the absence of a universal definition of treatment success. Future trials of MAD designs need to be assessed according to agreed success criteria in order to guide clinical practice as to which design of OAs may be the most effective in the treatment of OSA.

PMID: 21239397 [PubMed - as supplied by publisher]

The article states " These findings highlight the absence of a universal definition of treatment success." The definition of success should be the elimination of all obstructive apneas, hypopneas and RERA's or respiratory related arousals and/or UARS upper airway resistance syndrome. Ideally snoring should also be resolved. Success should also consider central apneas that are not treated by appliances. If there are substantial episodes of central apnea other alternatives may need to be considered.

Positional treatment and oral appliance therapy are frequently used together if incomplete results are obtained with just an oral appliance. It is important to remember that even patial therapy with an oral appliance is far superior to no therapy in patients who reject CPAP. The physician/dentist should try to eliminate all sleep disordered breating.

Allergies and nasal congestion can be addresses with nasal breathing strips, medication, correction of deviated septums or reduction of turbinates.

Irrigation with a Netti Pot utilizing saline or black tea and saline can reduce mucous congestion. I have seen several patients who clain great relief from NAET, I do not understand or endorse this therapy but I have seen many patients who claim significant relief.

The bottom line, it is essential to control all apneic episodes. Untreated sleep apnea is dangerous and can be fatal. Heart disease, hear attacks, strokes, hypertension, short term memory loss, increased risk of motor vehicl accidents, earlier and more severe onset of dementia and/or Alzheimers are just the tip of the iceberg for possible negative consequences related to sleep apnea.

My advice: See a sleeep apnea dentist with experience and/or a mentor who is trained in multiple oral appliances. I am a Diplomate of the American Academy of Dental Sleep Medicine. There are many dentists who are well trained but have not received Diplomate status. Choosing a Diplomate in dental sleep medicine does insure a wide range of experience but is only one of many considerations.